Thursday, May 25, 2017

The executive budget — which is mandated by federal law to be submitted by the President of the United States to Congress — is rarely taken seriously because the legislative branch typically adopts a federal budget that does not come close to resembling the budget proposed by the executive branch. That said, it does signal the President's priorities for the coming year. Sadly, President Donald J. Trump's proposed budget makes clear that people living with HIV/AIDS (among many other chronic health conditions) aren't among his priorities.

There is an emerging pattern with Trump, which started during the presidential primary and continued throughout the general election...and now into his presidency. He routinely makes statements that completely contradict one another, and his proposed budget continued that trend.

How?

Trump's budget for the U.S. Department of Health & Human Services ("HHS") included legislative language relevant to the reauthorization of the Ryan White CARE Act, which is technically due for an update. The language reads:

"The Administration looks forward to working with Congress to reauthorize the Ryan White program to ensure that Federal funds are allocated to address the changing landscape of HIV across the United States. Reauthorization of the Ryan White program should include changes to the funding methodologies for Parts A and B to ensure that funds may be allocated to target populations experiencing high or increasing levels of HIV infections/diagnoses, such as minority populations, while continuing to support Americans that are already living with HIV across the nation. African Americans, for example, account for a higher proportion of new HIV diagnoses, those living with HIV, and those ever diagnosed with AIDS as compared to other races/ethnicities. The new Ryan White authorization should allow for resources to be focused on populations with disproportionately high rates of new infections/diagnoses."

Yet, that same budget called for draconian funding cuts to numerous federal programs specifically designed to assist people living with HIV/AIDS (including some authorized under the very same Ryan White). Among them:

The budget also calls for flat funding for many other HIV-specific programs, including the AIDS Drug Assistance Programs (ADAPs) at $899 million. That might be acceptable under "normal" conditions, but the President and the Republican-led Congress are simultaneously trying to rollback numerous protections provided under the Affordable Care Act ("ACA") — such as Medicaid expansion, and Essential Health Benefits. It includes significant cuts to programs authorized under the National Institutes of Health ("NIH"), as well as programs providing mental health services, housing assistance, and addiction treatment.

Trump's budget has been universally denounced by the HIV/AIDS and Viral Hepatitis communities, as noted herein:

Ken Bargar, Co-Chair, Florida HIV/AIDS Advocacy Network (FHAAN): "Somewhere the President's advisors failed him. These are budget cuts to peoples' lives, their medications, their care and their shelter. As advocates, we cannot allow this budget to get any traction or legitimize it in any way. Congress appropriates our country's spending and that's were we should put our efforts. Let's let every Member of Congress know we won't stand for an administration that is willing to kill it's own people."

Michael Ruppal, Executive Director of The AIDS Institute: "The country has made great progress in the fight against HIV/AIDS and STDs, but if these cuts are enacted, we will turn back the clock, resulting in more new infections, fewer patients receiving care, and ultimately, more suffering from diseases that are preventable and treatable."

William E. Arnold, President & CEO of the Community Access National Network: "The president’s budget fails to meet the rising tide of viral hepatitis at a time when we’re on the cusp of seeing a sharp rise in new Hepatitis C infections. Flat funding HCV programs, while also cutting key HIV-related programs will prove problematic as we attempt to address the growing number of individuals co-infected with both HIV, and HCV."

Jesse Milan, Jr., President & CEO of AIDS United: "We have seen historic decreases in the number of new HIV infections over the past six years because of sustained investments in prevention, and we have thousands of HIV positive Americans who have yet to achieve viral suppression through treatment programs. By cutting funding, the work we have done will be reversed, and all the work left to do will falter and put the health of our nation at risk."

Ryan Clary, Executive Director of the National Viral Hepatitis Roundtable (NVHR): "President Trump’s assault on the health care system through his unconscionable cuts to Medicaid and other vital safety net programs will cause severe harm to people living with and at risk for hepatitis B and C. If enacted, the result will be continued alarming increases in hepatitis B and C infections, high numbers of individuals unaware of their status, and needless death and suffering due to lack of access to care and treatment. NVHR calls on Congress to reject this budget immediately and work together to pass an appropriations bill that expands access to quality health care for all and increases badly needed funding for the Division of Viral Hepatitis at CDC."

Murray C. Penner, Executive Director of the National Alliance of State & Territorial AIDS Directors (NASTAD): "Together we will fight these cuts at every stage of the appropriations process. We need to protect these programs that provide life-saving treatment for those living with HIV and work to prevent the spread of HIV and STDs. We trust that Congress will agree and recognize that these cuts are harmful, short-sighted, and will damage our nation's public health infrastructure."

Edward Hamilton, Executive Director of the ADAP Educational Initiative: "The administration’s proposed budget cuts across multiple programs will set back the gains that have been made in domestic and worldwide HIV epidemics 20 years. With the proposed changes in Medicaid and the Affordable Care Act, ADAPs nationwide will collapse due to the unprecedented strains on their budgets from rising drug costs coupled with forecasted increased premiums."

People living with HIV/AIDS, as well as viral hepatitis and other chronic conditions, don't deserve to have a bullseye on them. Trump's proposed budget would fail our nation's most vulnerable and neediest people, and as such, Congress should ignore it.

Friday, May 19, 2017

The Patient Access Network (PAN) Foundation — a corporate partner of the ADAP Advocacy Association — announced that it opened its fund for HIV Prevention And Treatment. Presently, there are 56 HIV-related medications covered by this program.

The PAN Foundation is accepting applications for new and renewal patients. People needing financial reprieve from the cost of their HIV-related medications are eligible for assistance up to $3,400 per year (additional assistance may be available, subject to the availability of funding). In fact, nearly 60 disease-specific assistance programs to help patients pay for their out-of-pocket costs are made available by the organization.

The PAN Foundation is an independent, national 501 (c)(3) organization dedicated to helping underinsured patients with chronic and critical illnesses afford their out-of-pocket medical expenses. Over the last thirteen years, they have provided more than 700,000 underinsured patients with over $2.5 billion dollars in financial assistance.[1]

Thursday, May 11, 2017

Patients and families confronting chronic, debilitating or life-threatening conditions at any age and any disease stage require reliable and affordable access to high quality therapies and supportive services throughout the care continuum in the settings that are best for them to optimize their outcomes and experiences. Yet today’s disease-centric care is fragmented across multiple specialists, subspecialists and settings, creating pressures to navigate pathways-driven treatments that overlook quality of life, functional outcomes, other personal priorities or individual characteristics that matter a great deal to patients and their families.

We know that patients rarely experience their symptoms as one isolated problem and can benefit from care that is truly person-centered and involves shared decision making. To accomplish this person-centered health care transformation, knowing precisely what is important to patients and families is paramount. Progress also requires dedicated commitment to enhancing clinical communication that is person-centered and goal-directed – learned skills that are essential drivers for delivering value-based care.

Photo Source: paintalks.com

Better health care value begins with improved communication about goals of care and personal values. Patients and families consistently report that they want to be involved in understanding their disease prognosis and treatment options and making decisions about their care. We chose to address these concerns as part of a grant funded project through targeted online survey efforts. Our primary goal was to examine multiple thematic areas from a broad patient perspective designed to explore the dimensions of what matters to patients.

The following highlights the preliminary analysis of some of the data collected from our virology cohort (HIV+ patients), specifically around the theme of communication. Survey participants were asked a series of 5 questions to gather information on how they wanted to receive health information, how involved they wanted to be in making healthcare related decisions, discussing what matters to them when selecting a treatment option, and their comfort level in broaching the conversation about quality of life with their doctor.

When asked, “how do you like to approach making decisions about your treatment” over 65% of the respondents wanted to make decisions in partnership with their medical versus the 14% who wanted to make their decisions alone or the 5% wanted the physician to make the choice for them. An additional 14% wanted their doctor to explain all of the options to them in detail before working together to make a treatment choice. The message from this data point is clear and supports our hypothesis that patients want dialog and information from their medical team and they want to be partners in making treatment choices.

In regards to doctor initiated conversations about things that are important to the patient in their care (non-clinical outcomes) 60% of respondents stated that their doctor did ask them about “what is important to you as part of making plans for your treatment”. Although this data point is encouraging, what was most compelling was that over 95% of those who answered in the affirmative, followed this question with a positive response to the question “did you feel that your doctor took that information into account when making recommendations”. So not only were the able to have the conversation – but their input was valued and used to identify and select a treatment option that was of value to them.

While only a small selection of the 100+ questions asked in the Patient Value Survey, the preliminary data gathered around patient-provider conversation in regards to treatment and care is encouraging. Historically, the HIV population have been the groundbreakers and drivers of action and having a voice in the way their chronic condition is treated. As we continue to use the collected data to drive a better understanding of what matters to patients, and how best to equip them for conversations about their comprehensive care and planning treatments that provide them the quality of life that they are seeking, we will continue to reach out to our non-profit partners to ensure that all voices are being heard.

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Thursday, May 4, 2017

The American Health Care Act ("AHCA") is not the law of the land...but rather it still is the Affordable Care Act ("ACA") governing our nation's healthcare framework. Let’s preface this fact with the message advocates have been stumping for months: stay vigilant, stay active, and stay on top of your elected representatives. For policy “wonks” and advocates assessing how potential legislation affects the American public, policy impact matters just as much as the political environment.

The American Health Care Act passed the U.S. House of Representatives on the narrowest of margins at 217-213. Twenty Republicans voted “no” on deep concerns of both negative impact on access and quality of care, and due to their seats being vulnerable in the 2018 midterm election (Roll Call, 2017). This vote took three months, one failed vote earlier this year, and days of “arm twisting in the cloak room” to make it happen. For the culture of the House, it is somewhat extraordinary in modern times. Now the legislation rests in the hands of the U.S. Senate.

Photo Source: C-SPAN

The Senate, while subject to more of the weight of Presidential politics, is a different beast entirely (Washington Post, 2017). Presidential politics plays both in favor for those Senators aligned with the President and against those from contentious states due to vulnerability of the seats. With a narrow Republican majority in the Senate, the coming months will see the divisions of the House amplified and thus weakening the possibility of the AHCA in its current form (or any form for that matter) passing the Senate. Additionally, once a Congressional Budget Office “score” is available, the Senate parliamentarian must assess if the bill meets the requirements of the “Byrd rule” as the AHCA is a “reconciliation” measure. Amendments added to the bill as it moves through the Senate committees will further change the CBO score and may make passage even less likely.

Among topics of concern with the bill are popular ACA provisions like consumer protections regarding pre-existing conditions, annual and lifetime limits, and the ability for children to stay on their parents’ coverage until the age of twenty-six. Less popular, though still maintaining wide support is the Medicaid expansion. The AHCA weakens these provisions by giving states the option to “opt out” of Essential Health Benefits, attacking Community Health Ratings, and forming “risk pools” for people with pre-existing conditions. Of note, independent analysis has shown that to adequately fund state risk pools, the AHCA would need to provide for $25 billion of funding. Currently, the AHCA only offers $8 billion over the course of 5 years. The ACA provided for $5 billion and ran out of funds at the 3rd year. The AHCA also structures “punishments” for those who experience lapses in coverage and older Americans. Combining these facts with substituting current subsidies with tax credits, people will face greater likelihood of lapse in coverage and increases in rates due to being unable to afford coverage in the first place. All while cutting funding and adding caps to state Medicaid programs.

Medicaid funding cuts are of special note as Medicaid expansion has eased the burden of other assistance programs like state AIDS Drug Assistance Programs, shortening waiting lists for services, and providing direct and continuous care opportunities for the most vulnerable of the American public.

The aforementioned issues will continue to be the center of the debate on the AHCA and why the CBO has scored the AHCA to cause tens of millions to lose coverage over projected 10 years following implementation.

Differing views in the Senate that label the health care programming and policy as “entitlement” will compete strongly with the attitudes of moderate Republicans that the government should provide protections and an avenue of care for their constituents and consensus will be exceptionally difficult to find. What’s likely to bring moderates on board will alienate Libertarian-minded Republicans, and vice versa. Democrats are expected to behave as a “blue wall” and vote as a caucus against the AHCA. The two Democrat Senators to watch will be Joe Manchin (WV) and Heidi Heitkamp (ND), as the most likely to indicate if the AHCA may gain even a single blue vote and thus is altered enough to gain a moderate majority.

Photo Source: trofire.com

The best way for constituents and advocates to make their voices known is, and will always be, to call their elected representatives offices, both at home and in DC, show up to town hall meetings, and take action with advocacy organizations aligned with their values.

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.